Provider Demographics
NPI:1558517102
Name:MICHAEL OBRIEN MD PA
Entity Type:Organization
Organization Name:MICHAEL OBRIEN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-367-2802
Mailing Address - Street 1:901 N CURTIS RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1338
Mailing Address - Country:US
Mailing Address - Phone:208-367-2802
Mailing Address - Fax:208-375-8755
Practice Address - Street 1:901 N CURTIS RD
Practice Address - Street 2:SUITE 101
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1338
Practice Address - Country:US
Practice Address - Phone:208-367-2802
Practice Address - Fax:208-375-8755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-14
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM2977174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002425500Medicaid